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Highlights from this issue
  1. The Triumvirate
  1. Lane Fox Respiratory Service, Guy’s & St Thomas' NHS Foundation Trust, London, UK

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It’s what he would have wanted…

Some time in the mid-seventies film director Woody Allen said: ‘I’m not afraid of death; I just don’t want to be there when it happens.’ We might all prefer to postpone thinking about our inevitable demise but this course of action is unwise when one’s demise is imminent. NHS choices describes advance care planning as: ‘…thinking and talking about your wishes for how you are cared for in the final months of your life’. On page 222 of this month’s journal Jabbarian and colleagues describe the results of a systematic review of advance care planning for patients with chronic respiratory diseases. They conclude that, while most patients would like to make such plans, most do not. Barriers to advance care planning include: the complex disease course; professional reluctance to extinguish hope and lack of continuity of care. Beware though - Woody Allen also said: ‘If you want to make God laugh, tell him about your plans.’

An epic EPICC?

When asked to think of an epic you might suggest a film like Ben-Hur or Laurence of Arabia. What might not spring to mind is a randomised controlled trial of intensive versus standard physical rehabilitation therapy in the critically ill (EPICC). Wright et al describe the findings of this RCT, where critical care patients were randomised to 90 min vs. 30 min physical rehabilitation per day ( see page 213 ). The primary outcome (at 6 months) was the physical component summary of the SF-36 Health Survey – a quality of life questionnaire comprising a mere 36 items. The study achieved the required sample size but found no difference between regimens. The authors highlight participant fatigue as a major factor preventing therapists delivering the target duration of rehabilitation. Making an EPICC is an exhausting business!

Raw milk for pre-schoolers?

For many children, the only ‘early-life farm exposure’ they will have had is seeing the film Babe on the large or small screen. On page 279 of the journal, Wyss and colleagues describe the relationship between raw milk consumption and other early-life farm exposures vs. adult pulmonary function. ‘Raw’ milk, by the way, means unpasteurised. Raw milk consumption was associated with a higher FEV1 and FVC. The strongest relationship was with drinking raw milk before the age of 6 years (observed in participants of mean age 63 years). We are not told whether the study participants suffered from infections which can be transmitted by unpasteurised milk such as Salmonella or Listeria.

Lawrence of Arabia and MERS

We can only speculate whether any of the camels featured in David Lean’s epic film Lawrence of Arabia suffered from ‘camel ’flu’ or Middle East respiratory syndrome (MERS). It seems unlikely as the first cases were described in 2012. In this month’s Thorax, Hong et al describe the risk factors for mortality in 30 (human) patients with MERS ( see page 286 ). Clinical risk factors (on admission) were older patients, those with a low albumin, an altered mental state and a high pneumonia severity index score. Raised inflammatory mediators and a high viral load also conferred risk. We are not told what the risk factors are for camels…

Smoking, telomeres and the movies

Hollywood has long had a love affair with smoking. The airtime given to tobacco in the movies has declined a little since the days when Humphrey Bogart lit up in Casablanca. But what about the telomeres? On page 283 of the journal, Andujar and colleagues describe the relationship between telomere length and smoking. They describe how short telomere length in peripheral leucocytes may be a marker for increased susceptibility to the effects of smoking. We will never know whether Humphrey Bogart had long or short telomeres but we do know his final illness was not respiratory. He died from carcinoma of the oesophagus.

The social network

The interweb has come a long way in the short time since we were searching the Index Medicus in our medical school libraries. The Social Network describes the origins of Facebook, a web based platform that is generally not considered suitable for children, as quirky idea that became a worldwide phenomenon. In this issue of Thorax, Dr Griese describes the origins of ChILD-EU ( see page 231 ). While it may sound like the sort of blunt, awkward observation that the protagonist might have barked in the movie it is, in fact, an international web based management platform for Childhood Interstitial Lung Disease. 575 patients were assessed over 3 years by an international multidisciplinary team and they found that 13% of the referral diagnoses were not confirmed by peer review. As Zuckerberg would say ‘I’m totally psyched about this too’.

The bells of st mary’s

Tuberculosis is a rich source of celluloid drama. Ingrid Bergman famously played Sister Mary who frequently squabbles with Father Chuck O’Malley, played by Bing Crosby, before she contracts TB. Both were nominated for Oscars for their roles but Bing Crosby’s nomination was notable for being the first time an actor was nominated twice for the same role, having previously played Father Chuck O’Malley in Going My Way. In this issue, Dr Shi and colleagues undertake two prospective studies assessing the levels of Interleukin 27 to diagnose tuberculous pleural effusions ( see page 240). In a meta-analysis of the two studies they confirmed the positive and negative predictive values of around 98% and they suggest a value below 591.4 ng/L rules out tuberculous effusions. While Crosby was nominated for three Oscars he won only one. Maybe if the Academy of Motion Picture Arts and Sciences did meta-analyses?

Taking a ribbing…

In pulmonary imaging, don’t overlook the ribs. See page 300 to expand your list of differentials for sub-pleural cysts.


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